M7: Improving Transitions and Reducing Avoidable Rehospitalizations. St. Luke s Hospital Member, Iowa Health System

Size: px
Start display at page:

Download "M7: Improving Transitions and Reducing Avoidable Rehospitalizations. St. Luke s Hospital Member, Iowa Health System"

Transcription

1 M7: Improving Transitions and Reducing Avoidable Rehospitalizations Peg M. Bradke, RN, MA St. Luke s Hospital, Cedar Rapids, Iowa This presenter has nothing to disclose. St. Luke s Hospital Member, Iowa Health System Private hospital Cedar Rapids, Iowa Affiliate in the Iowa Health System Licensed for 500 Beds with more than 17,000 admissions Thomson-Reuters Top 100 Heart Hospital 3 years Iowa Recognition for Performance Excellence Gold Award Magnet Designation The Joint Commission Disease- Specific Certification for Heart Failure since 2008; Stroke since 2006; Chest Pain Accreditation

2 Why is Reducing Avoidable Rehospitalizations Strategic for St. Luke s Hospital? It is part of our mission: To give the care we would like our loved ones to receive. It represents goals that are aligned with health care reform: providing better value for decreased costs. Heart Failure Team Formed in 2001 In February 2006, St. Luke s joined the RWJF/IHI TCAB Collaborative with a focus on improving discharge processes and reducing avoidable rehospitalizations Initial focus was on the heart failure population with the goal of creating an ideal transition to home In 2010, changed focus to all Core Measure patients to develop reliable processes to ensure smooth transitions and compliance with CMS Core Measures 2

3 Heart Failure Team Members Peg Bradke, Chair, Heart Care Svcs. Robinn Bardell, PI Ann Beem, PCC-3C Alexis Benion, Living Center West Christy Charkowski, STL Hospitalists Krissy Elder, PCC-5C Karen Forster, Pharm Terri Grantham, Card Outcomes Renee Grummer-Miller, OP Pal. Care Barb Haeder, Card Outcomes Sue Halter, Card Outcomes Lesley Haro, Ortho Sherrie Justice, Dir-PI Carmen Kinrade, Dir-Med/Surg Shirley McCloy, Resp Ther Sandi McIntosh, Dir-ED Signe Munson, VNA Jennifer Owens, Med Soc Svcs Julie Peterson, Mgr-Card Rehab Diane Pfeiler, Mgr-5E Kelly Pottebaum, PCC-5E Nikki Robson, Pal Care Amy Schweer, CLC -#944 Aimee Traugh, Mgr-3C Jean Vorwald, VNA Jean Westerbeck, Living Center West Pam Williams, JRMC Resp Care Sharon Zimmerman, Resp Care AD HOC: Doralyn Benson, Mgr-Med Soc Svcs Dena Fisher, STL Hospitalists Cross-Continuum Team Meets every other week Reviews readmission to assess causes and opportunities for improvement Reviews process and outcome measures Continually makes improvements, aggregating the experiences of patients, families and caregivers. Provides oversight for CMS Core Measures 3

4 Heart Failure Continuum of Care Standardized care through order sets Patients identified via BNP daily reports Teaching Utilizing Universal Health Literacy Concepts Enhanced teaching materials Teach Back Touch points Home Care -care coordination visit 24 to 48 hours post discharge Hospital Based Heart Failure Clinic visit in 3-5 days with subsequent visits established with clinic and PCP based on needs of each individual Follow-up phone call on post discharge at 5-9 days Outpatient Heart Failure class Enhanced Admission Assessment During Admission Assessment, the patient and family are asked, Who would you like to have present when we provide your discharge information? Information added to the whiteboard. RN and physician do medication reconciliation. At times, the pharmacy or physician offices need to be called to get additional information. If the patient is a home care patient, the home care agency is called to get the current list of medications. Automatic referral to Respiratory Care for all new inhaler orders for inhaler education. 4

5 Enhanced Admission Assessment (2) Referral to Palliative Care for patient with advanced stages of disease -The referrals have increased from less than 5% to over 20%. Bedside report to involve the patient and family caregivers as partners in their care. Daily discharge huddle is facilitated daily with the RN caring for the patient, the charge nurse, and unit-based case manager. Daily goals are reviewed and written on the whiteboards in each room, providing the opportunity to review the plan for the day, anticipate discharge needs, and determine what it will take to get the patient home safely. 5

6 Whiteboard Update New Section: Goal to Go Home Current State: We have the anticipated d/c date in the upper left box. This is an area that has not been filled out for a variety of reasons. Often, there was a discrepancy in the date among the HCT or uneasiness in putting an exact date in for fear the date would change and patient and family would lose some trust. Test of Change: 3C and 5E trialed a new entry on the whiteboard. A small additional magnet has been added to address Goal to Go Home. It is put in the Plan and Goal for the Daybox. Feedback from the staff was positive. They found this provided a more tangible step that the patient and family must achieve to be sent home. It can aid in engaging the patient and family more in working towards the time to discharge which is part of our CARE MODEL. We hear over and over again how much our patients/ families and the healthcare team rely on the whiteboards for information. This new way to address goals towards discharge seems to meet our patient/family needs better. Whiteboard Update (2) New Section: Goal to Go Home Outcome: We will now be adding this item to all the standard whiteboards. The Daily Goals will continue to be changed daily. The Goal to Go Home for the most part will probably not change. Below is an example for a Heart Failure patient. Plan/Goal for the Day Walk to Nurse s Station and back 2 times today Eat all meals out of bed. Goal to Go Home Learn Heart Failure diet plan to go home Weigh self and monitor changes in weight Identify Warning Signs and Symptoms to report to doctor 6

7 Enhanced Teaching and Learning The patient education materials facilitate the use of teach-back, and the same materials are used across the continuum: in the hospital, with home care, long-term care settings and the clinic. Teach-back -the process of asking patients to recall and restate in their own words what they have been taught -was incorporated at the patient s bedside during the hour post-discharge followup visit by Home Health and in the seventh day post-discharge phone call to the patient. Short, succinct material developed for each Core Measure DRG Teach-back question part of packet for staff and patient reference Patients and families are given a 12-month calendar for Heart Failure Patient teaching flowsheets are set up to address teach-back and assure the documentation and utilization of the technique. Lung Packet Contents Cover page Inside 7

8 Heart Failure Magnet Heart Failure Zones 8

9 17 9

10 10

11 11

12 Teach-back with Discharge Instructions Can you show me on these instructions: How you find your doctors office appointment? What other tests you have scheduled and when? Is there anything on these instructions that could be difficult for you to do? Have we missed anything? Successful Teach-back Rate Aug 06 Aug11 VNA teachback initiated Follow-up phone calls initiated Nurse competency evaluations in health literacy started Updated 9/26/11 12

13 Post-Acute Care Follow-Up Home Care Visit set up for 3-5 days. Home Care liaison in-house. At 5-10 days, a hospital nurse conducts a follow-up phone call. During this call, the RN uses the same teachback questions used in the hospital to determine the patient and/or caregiver understanding of the critical self-care instructions. HF patients called through Clinic, Hospitalist program calls their patients after discharge. Partnership with physicians offices resulted in redesign of scheduling HF visits to allow office visits within 3 to 5 days for all patients with HF in HF Clinic. Subsequent appointments established with Clinic, PCP or specialist based on patient s assessment and need. The Cross Continuum Team continually makes improvements by aggregating the experiences of the patients, families and caregivers. Readmissions are monitored, and failures are reviewed by the Cross Continuum Team to assess opportunities for improvement. Attending MD during Hospitalization (11/07 10/11) 13

14 Discharge Status (11/07 10/11) Real-time Handover Communications Medication Reconciliation is a joint physician and nurse accountability. The physician is provided a report at discharge to reconcile home medication list with those in hospital. The nurse puts the reconciled list in the patient s discharge instructions. All patients going home are offered a care coordination visit with Home Care in the first hours after discharge. The home care does a certified content visit including medication reconciliation. St. Luke s partnered with the hospital s home care agency (VNA) and two long-term care facilities to standardize and enhance the quality of the handoff communication process. Standardized form. Warm handover with those patients with complex issues. Provided education for home care and long-term and skilled care RNs and CNAs on HF and continuity process. CNAs often observe symptoms. Provided the receiving nursing home facilities with the patient education packet. 14

15 Number of Days after Discharge Patients are Readmitted # of patients readmitted # of days between discharge and readmission Three to Five-Day Follow-up (Nov 07 Aug 11) Updated 9/26/11 15

16 Heart Failure Readmissions (for Any Cause) within 30 Days 35% 30% 25% Percent 20% 15% 10% 5% 0% YTD %HF to Any Reason Median 16

17 Heart Failure Readmissions (for Any Cause) within 30 Days 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% 2006 Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q1 Percent 2011 Q2 %HF to Any Reason Median HCAHPS RESULTS DISCHARGE INFORMATION (% Yes) Dec-07 Apr Jun-10 Sep-10 Dec-10 St. Luke's National #19 During hospital stay, did doctors, nurses or other hospital staff talk about whether you would have the help you needed when you left the hospital? #20 During the hospital stay, did you get the information in writing about what symptoms or health problems to look out for after you left the hospital? 17

18 Leadership Activities and Learning Executive Leader facilitates reports to Senior Leaders and Board Day-to-Day Leader manages bi-weekly Transition to Home meetings and assures ongoing testing and implementation of changes and monitors results Barriers and Breakthroughs Limitations of the electronic medical record to capture and transmit information. Access to physician offices for follow-up visits. Complexity of patients with multiple comorbidities. Challenges to completing reliable medication reconciliation. 18

19 Lessons Learned Importance of engaged executive leaders Explicit focus on patient and family-centered work Front-line clinicians and staff involvement in developing process improvements Physician engagement Cross Continuum Team power of relationship building and collaboration Importance of understanding patients home environment Impact of Information Technology Stories are as important as the data 19

IHI S APPROACH TO REDUCING REHOSPITALIZATIONS IN THE STAAR INITIATIVE: OVERVIEW

IHI S APPROACH TO REDUCING REHOSPITALIZATIONS IN THE STAAR INITIATIVE: OVERVIEW Session M1 This presenter has nothing to disclose IHI S APPROACH TO REDUCING REHOSPITALIZATIONS IN THE STAAR INITIATIVE: OVERVIEW Pat Rutherford, RN, MS, Vice President, Institute for Healthcare Improvement,

More information

REDUCING READMISSIONS

REDUCING READMISSIONS REDUCING READMISSIONS UnityPoint Health - St. Luke s Hospital Cedar Rapids, Iowa IHI National Forum December 2014 - Orlando, Florida ST. LUKE S HOSPITAL UNITYPOINT HEALTH SYSTEM Private hospital Cedar

More information

Improvements in Care-Transitions: A Case Study of St. Luke s Hospital

Improvements in Care-Transitions: A Case Study of St. Luke s Hospital [CASE STUDY] January 18, 2012 Improvements in Care-Transitions: A Case Study of St. Luke s Hospital Prepared for the Centers for Medicare and Medicaid Services 2012 The Brookings Institution Foreword The

More information

Reducing Readmission Case Stories Discussion of Successes

Reducing Readmission Case Stories Discussion of Successes Reducing Readmission Case Stories Discussion of Successes University of California, San Francisco Maureen Carroll RN, CHFN Transitional Care Manager Heart Failure Program Coordinator UnityPoint Cedar Rapids

More information

IHI Expedition. Reducing Readmissions by Improving Care Transitions Session 2. Expedition Coordinator

IHI Expedition. Reducing Readmissions by Improving Care Transitions Session 2. Expedition Coordinator Thursday, June 20, 2013 These presenters have nothing to disclose IHI Expedition Reducing Readmissions by Improving Care Transitions Session 2 Peg Bradke, RN, MA Saranya Loehrer, MD, MPH Expedition Coordinator

More information

Community Care Coordination Cross Continuum Care IHC Medical Home Conference September 5, 2012 Des Moines IA

Community Care Coordination Cross Continuum Care IHC Medical Home Conference September 5, 2012 Des Moines IA Community Care Coordination Cross Continuum Care IHC Medical Home Conference September 5, 2012 Des Moines IA Peg Bradke, RN, MA Director of Heart Care Services St. Luke s Hospital, Cedar Rapids, IA Session

More information

Developing Post- Hospital Follow-Up Care Plans and Real-time Handover Communications Peg Bradke

Developing Post- Hospital Follow-Up Care Plans and Real-time Handover Communications Peg Bradke These presenters have nothing to disclose Developing Post- Hospital Follow-Up Care Plans and Real-time Handover Communications Peg Bradke September 28, 2015 Session Objectives Participants will be able

More information

Minicourse Objectives

Minicourse Objectives Session M1 This presenter has nothing to disclose SINAI-GRACE HOSPITAL Vanguard Health Systems/Detroit Medical Center Peggy Segura RN, MSN, FNP-BC Nurse Practitioner, Quality & Safety/Clinical Effectiveness

More information

IHI Expedition Reducing Readmissions by Improving Care Transitions Session 4

IHI Expedition Reducing Readmissions by Improving Care Transitions Session 4 Thursday, July 25, 2013 These presenters have nothing to disclose IHI Expedition Reducing Readmissions by Improving Care Transitions Session 4 Peg Bradke, RN, MA Saranya Loehrer, MD, MPH Expedition Coordinator

More information

Presenter Disclosure Information

Presenter Disclosure Information The following program is co-provided by the American Heart Association and Health Care Excel, the Medicare Quality Improvement Organization for Kentucky. 3/1/2013 2010, American Heart Association 1 1 2

More information

Rhonda Dickman, RN, MSN, CPHQ

Rhonda Dickman, RN, MSN, CPHQ Rhonda Dickman, RN, MSN, CPHQ Rhonda Dickman is a Quality Improvement Specialist with the Tennessee Hospital Association s Tennessee Center for Patient Safety, supporting hospitals in their quality improvement

More information

L19: Improving Transitions from the Hospital to Post Acute Care Settings

L19: Improving Transitions from the Hospital to Post Acute Care Settings This presenter has nothing to disclose L19: Improving Transitions from the Hospital to Post Acute Care Settings Gail A. Nielsen December 8, 2013 25th Annual National Forum on Quality Improvement in Health

More information

EXECUTIVE SUMMARY: briefopinion: Hospital Readmissions Survey. Purpose & Methods. Results

EXECUTIVE SUMMARY: briefopinion: Hospital Readmissions Survey. Purpose & Methods. Results briefopinion: Hospital Readmissions Survey EXECUTIVE SUMMARY: Purpose & Methods The purpose of this survey was to collect information about hospital readmission rates and practices. The survey was available

More information

Transitions of Care Innovations in the Medical Practice Setting

Transitions of Care Innovations in the Medical Practice Setting Transitions of Care Innovations in the Medical Practice Setting Linda Wendt, System Director of Quality- UnityPoint Clinic Sheila Tumilty, Senior Project Manager- UnityPoint Clinic Session Objectives After

More information

Heart Failure Order Sets. Standardizing Care for the Heart Failure Patient 2012

Heart Failure Order Sets. Standardizing Care for the Heart Failure Patient 2012 Heart Failure Order Sets Standardizing Care for the Heart Failure Patient 2012 Objectives: Standardize care for all heart failure patients in Legacy Base Practice on American Heart Association Guidelines

More information

Readmission Reduction: Patient Interviews. KHA Quality Conference March, 2018

Readmission Reduction: Patient Interviews. KHA Quality Conference March, 2018 Readmission Reduction: Patient Interviews KHA Quality Conference March, 2018 Initial Driver Diagram Use Data and Root Cause Analysis to drive Continuous Improvement Analyze data to inform targeting approach

More information

Patient Interview/Readmission Chart Review. Hospital Review:

Patient Interview/Readmission Chart Review. Hospital Review: Appendix: Readmission Review Form Patient Interview/Readmission Chart Review Patient Name: Previous Hospital Admission Date Account Number Previous Hospital D/C Date: D/C MD: Previous Hospital Discharge

More information

Rutherford P, Nielsen GA, Taylor J, Bradke P, Coleman E. How to Guide: Improving Transitions from the Hospital to Community Settings to Reduce

Rutherford P, Nielsen GA, Taylor J, Bradke P, Coleman E. How to Guide: Improving Transitions from the Hospital to Community Settings to Reduce Teaching Patients Patient-friendly written materials use: Simple words (1-2 syllables) Short sentences (4-6 words) Short paragraphs (2-3 sentences) No medical jargon Headings and bullets Highlighted or

More information

WebEx Quick Reference

WebEx Quick Reference IHI Expedition: Effective Implementation of Heart Failure Core Processes Peg Bradke, RN, MA, Faculty Christine McMullan, MPA, Director December 15, 2011 These presenters have nothing to disclose WebEx

More information

The STAAR Initiative

The STAAR Initiative The STAAR Initiative Getting Started Kit for the STAAR Collaborative September 2010 Institute for Healthcare Improvement, 2010 Page 1 Table of Contents STAAR Collaborative Charter... 3 Statement of Need...

More information

Baystate Medical Center

Baystate Medical Center Baystate Medical Center STAAR Collaborative February 2 & 3 2011 680 bed tertiary care referral center ( ~1M) Flagship of Baystate Health 42 k admissions/year Annual surgical volume: 29,043 Western Campus

More information

National Readmissions Summit Safe and Reliable Transitions: An Integrated Approach Reducing Heart Failure Readmissions

National Readmissions Summit Safe and Reliable Transitions: An Integrated Approach Reducing Heart Failure Readmissions National Readmissions Summit Safe and Reliable Transitions: An Integrated Approach Reducing Heart Failure Readmissions Michael Kanter, MD, Medical Director Quality and Clinical Analysis Patti Harvey, RN,

More information

CHF Readmission Initiative. Mary Fischer MSN, CCRN, PCCN, CHFN Cardiology Clinical Nurse Specialist St. Vincent Hospital Indianapolis, Indiana

CHF Readmission Initiative. Mary Fischer MSN, CCRN, PCCN, CHFN Cardiology Clinical Nurse Specialist St. Vincent Hospital Indianapolis, Indiana CHF Readmission Initiative Mary Fischer MSN, CCRN, PCCN, CHFN Cardiology Clinical Nurse Specialist St. Vincent Hospital Indianapolis, Indiana St. Vincent 86 th Street Campus Heart Failure Program History

More information

CareTrek : Nebraska s Journey to Safe Care Transitions

CareTrek : Nebraska s Journey to Safe Care Transitions CareTrek : Nebraska s Journey to Safe Care Transitions Audrey Paulman, MD, MMM Principal Clinical Coordinator CIMRO of Nebraska This material was prepared by CIMRO of Nebraska, the Medicare Quality Improvement

More information

PRISM Collaborative: Transforming the Future of Pharmacy PeRformance Improvement for Safe Medication Management

PRISM Collaborative: Transforming the Future of Pharmacy PeRformance Improvement for Safe Medication Management PRISM Collaborative: Transforming the Future of Pharmacy PeRformance Improvement for Safe Medication Management Mission: To improve the health of the people of Connecticut through safe and effective medication

More information

Improving Transitions to Home & Community- Based Care Settings

Improving Transitions to Home & Community- Based Care Settings This presenter has nothing to disclose. Improving Transitions to Home & Community- Based Care Settings Eric Coleman September 29, 2015 Session Objectives Participants will be able to: Describe the role

More information

Leveraging the Accountable Care Unit Model to create a culture of Shared Accountability

Leveraging the Accountable Care Unit Model to create a culture of Shared Accountability Leveraging the Accountable Care Unit Model to create a culture of Shared Accountability How we improved Patient Safety and Quality Outcomes at Northwest Hospital Our Journey to Shared Accountability Implementation

More information

NYSPFP- Readmission Collaborative Domain II - Kick-off Webinar Improving Care Transitions Between Hospitals and SNFs

NYSPFP- Readmission Collaborative Domain II - Kick-off Webinar Improving Care Transitions Between Hospitals and SNFs NYSPFP- Readmission Collaborative Domain II - Kick-off Webinar Improving Care Transitions Between Hospitals and SNFs February 28, 2017 A partnership of the Healthcare Association of New York State and

More information

L4: Getting to Always! Using teach-back to Maximize Patient Learning

L4: Getting to Always! Using teach-back to Maximize Patient Learning These presenters have nothing to disclose 15th Annual International Summit on Improving Patient Care in the Office Practice and the Community Sunday March 9 - Tuesday, March 11, 2014 L4: Getting to Always!

More information

Presenter Disclosure

Presenter Disclosure Improving Transitions from the Hospital to Community Settings IHI National Forum Learning Lab Sunday, December 8, 2013 Presenter Disclosure MaryAnne Elma, MPH Quality Implementation and Innovations Director

More information

Enhanced Assessment for Post Hospital Needs

Enhanced Assessment for Post Hospital Needs These presenters have nothing to disclose Enhanced Assessment for Post Hospital Needs Maureen Carroll September 28, 2015 Session Objectives Participants will be able to: Identify failures in current processes

More information

Strategies to Reduce Readmissions, Sepsis, and Health-Care Associated Infections

Strategies to Reduce Readmissions, Sepsis, and Health-Care Associated Infections C10 This presenter has nothing to disclose Strategies to Reduce Readmissions, Sepsis, and Health-Care Associated Infections David Renfro, MS, RN NE BC Kelly Farnam, BSN, RN Gloria Martinez, MS, RN, NEA

More information

The Community Care Navigator Program At Lawrence Memorial Hospital

The Community Care Navigator Program At Lawrence Memorial Hospital The Community Care Navigator Program At Lawrence Memorial Hospital Presented By: Linda Gall, MSN, RN, ACM Director of Care Coordination October 21, 2011 Learning Objectives: 1. Describe the vision and

More information

COPD & Pneumonia Readmission Reduction Program. October 25, 2017

COPD & Pneumonia Readmission Reduction Program. October 25, 2017 COPD & Pneumonia Readmission Reduction Program October 25, 2017 Susan J. Bowers, MBA, BSN, RN Chief Quality Officer Mercy Health - Lorain 2 Locations Mercy Health Lorain Hospital Lorain, Ohio 250 bed community

More information

Readmission Project 2017 Janice M. Maupin, RN, MSN, CPHQ. A Catholic healthcare ministry serving Ohio and Kentucky

Readmission Project 2017 Janice M. Maupin, RN, MSN, CPHQ. A Catholic healthcare ministry serving Ohio and Kentucky Readmission Project 2017 Janice M. Maupin, RN, MSN, CPHQ A Catholic healthcare ministry serving Ohio and Kentucky 1 Mission, Values and Promise Our Mission We extend the healing ministry of Jesus by improving

More information

Improving Care Transitions for Rhode Island Patients

Improving Care Transitions for Rhode Island Patients Improving Care Transitions for Rhode Island Patients Nelia Odom, RN, BSN, MBA, MHA Senior Program Coordinator, Quality Partners of Rhode Island Deborah Correia Morales, MSW Senior Program Coordinator,

More information

The STAAR Initiative

The STAAR Initiative The STAAR Initiative A quality effort at the heart of system redesign Amy E. Boutwell, MD, MPP The Center for Innovative Healthcare Strategies amy@innovativehealthcarestrategies.org Please note: Dr Boutwell

More information

CareTrek : Nebraska s Journey to Safe Care Transitions

CareTrek : Nebraska s Journey to Safe Care Transitions CareTrek : Nebraska s Journey to Safe Care Transitions Audrey Paulman, MD, MMM Principal Clinical Coordinator CIMRO of Nebraska This material was prepared by CIMRO of Nebraska, the Medicare Quality Improvement

More information

Designing & Delivering Whole-Person Transitional Care Coordinating care across settings and over time to drive outcomes

Designing & Delivering Whole-Person Transitional Care Coordinating care across settings and over time to drive outcomes Designing & Delivering Whole-Person Transitional Care Coordinating care across settings and over time to drive outcomes Amy E. Boutwell, MD, MPP CNYCC Annual Meeting November 6, 2017 Agenda Design data,

More information

Reducing Hospital Readmissions: Home Care as the Solution

Reducing Hospital Readmissions: Home Care as the Solution Reducing Hospital Readmissions: Home Care as the Solution Kathy Duckett RN, BSN Sutter Center for Integrated Care ducketk@sutterhealth.org www.suttercenterforintegratedcare.org Learning Objectives 1 Review

More information

The BOOST California Collaborative

The BOOST California Collaborative The BOOST California Collaborative California HealthCare Foundation Hospital Association of Southern California LA Care Health Plan The John A. Hartford Foundation Objectives for the Day Review the rationale

More information

VNAA BLUEPRINT FOR EXCELLENCE BEST PRACTICES TO REDUCE HOSPITAL ADMISSIONS FROM HOME CARE. Training Slides

VNAA BLUEPRINT FOR EXCELLENCE BEST PRACTICES TO REDUCE HOSPITAL ADMISSIONS FROM HOME CARE. Training Slides VNAA BLUEPRINT FOR EXCELLENCE BEST PRACTICES TO REDUCE HOSPITAL ADMISSIONS FROM HOME CARE Training Slides 061015 Why Take Action to Prevent Readmissions? Better patient care and patient experience Home

More information

Post-Acute Care Networks: How to Succeed and Why Many Fail to Deliver JULY 18, 2016

Post-Acute Care Networks: How to Succeed and Why Many Fail to Deliver JULY 18, 2016 Post-Acute Care Networks: How to Succeed and Why Many Fail to Deliver HEALTH FORUM AND AHA LEADERSHIP SUMMIT JULY 18, 2016 SAN DIEGO, CALIFORNIA Please note that the views expressed are those of the conference

More information

How-to Guide: Improving Transitions from the Hospital to the Clinical Office Practice to Reduce Avoidable Rehospitalizations

How-to Guide: Improving Transitions from the Hospital to the Clinical Office Practice to Reduce Avoidable Rehospitalizations How-to Guide: Improving Transitions from the Hospital to the Clinical Office Practice to Reduce Support for the How-to Guide was provided by a grant from The Commonwealth Fund. Copyright 2012 Institute

More information

Improving Patient Safety Across Michigan and Illinois

Improving Patient Safety Across Michigan and Illinois Improving Patient Safety Across Michigan and Illinois Grand Rounds April 6, 2016 1 Agenda Grand Rounds Overview and Questions Care Transitions Vignette Fairfield Memorial s Care Check Program Grand Rounds

More information

Minicourse Objectives

Minicourse Objectives Session M1 This presenter has nothing to disclose IHI s Approach to Reducing Rehospitalizations in the STAAR Initiative: Overview Pat Rutherford, RN, MS, Vice President, Institute for Healthcare Improvement,

More information

Preventing Heart Failure Readmissions by Using a Risk Stratification Tool

Preventing Heart Failure Readmissions by Using a Risk Stratification Tool Preventing Heart Failure Readmissions by Using a Risk Stratification Tool Anna Dermenchyan, MSN, RN, CCRN-K Senior Clinical Quality Specialist Department of Medicine, UCLA Health PhD Student, UCLA School

More information

Transitions of Care: Primary Care Perspective. Patrick Noonan, DO

Transitions of Care: Primary Care Perspective. Patrick Noonan, DO Transitions of Care: Primary Care Perspective Patrick Noonan, DO Disclosures None Bio Outpatient primary care internist at New Pueblo Medicine Completed residency at the University of Iowa Graduated from

More information

Post-Acute Care Networks: How to Succeed and Why Many Fail to Deliver JULY 18, 2016

Post-Acute Care Networks: How to Succeed and Why Many Fail to Deliver JULY 18, 2016 Post-Acute Care Networks: How to Succeed and Why Many Fail to Deliver HEALTH FORUM AND AHA LEADERSHIP SUMMIT JULY 18, 2016 SAN DIEGO, CALIFORNIA Please note that the views expressed are those of the conference

More information

Interprofessional Rounding Presentations

Interprofessional Rounding Presentations Interprofessional Rounding Presentations Sue Kelly & Diana Williamson, Grey Bruce Health Services Sandi Pincombe, St. Thomas Elgin General Hospital Sheila Hunt, London Health Sciences Centre INTER-PROFESSIONAL

More information

Using Facets of Midas+ Hospital Case Management to Support Transitions of Care. Barbara Craig, Midas+ SaaS Advisor

Using Facets of Midas+ Hospital Case Management to Support Transitions of Care. Barbara Craig, Midas+ SaaS Advisor Using Facets of Midas+ Hospital Case Management to Support Transitions of Care Barbara Craig, Midas+ SaaS Advisor What does Transitional Care Include? Transitional Care is the smooth conversion of a patient

More information

Lost in Transition. Definition. Objectives 9/22/2014

Lost in Transition. Definition. Objectives 9/22/2014 Lost in Transition Eliza Borzadek, RN, Pharm.D., BCPS Idaho State University eliza@fmed.isu.edu ISHP Annual Fall Conference: September 26-28, 2014 Objectives 1. Describe the background and history of transitions

More information

IHI Expedition. Reducing Readmissions by Improving Care Transitions Session 1. Expedition Coordinator

IHI Expedition. Reducing Readmissions by Improving Care Transitions Session 1. Expedition Coordinator Thursday, June 6, 2013 These presenters have nothing to disclose IHI Expedition Reducing Readmissions by Improving Care Transitions Session 1 Peg Bradke, RN, MA Saranya Loehrer, MD, MPH Expedition Coordinator

More information

H2H Mind Your Meds "Challenge. Webinar #3- Lessons Learned Wednesday, April 18, :00 pm 3:00 pm ET. Welcome

H2H Mind Your Meds Challenge. Webinar #3- Lessons Learned Wednesday, April 18, :00 pm 3:00 pm ET. Welcome H2H Mind Your Meds "Challenge Webinar #3- Lessons Learned Wednesday, April 18, 2012 2:00 pm 3:00 pm ET 1 Welcome Take Home Messages Understand how to implement the Mind Your Meds strategies and tools in

More information

The Stepping Stones Project Community Engagement to Reduce Unnecessary Rehospitalizations

The Stepping Stones Project Community Engagement to Reduce Unnecessary Rehospitalizations The Stepping Stones Project Community Engagement to Reduce Unnecessary Rehospitalizations Evan Stults Executive Director, Communications Quality & Safety Initiatives Qualis Health Seattle, Washington About

More information

Improving Patient Outcomes through Quality Transitions

Improving Patient Outcomes through Quality Transitions Improving Patient Outcomes through Quality Transitions Founded in 1892, Union Hospital began as a 20 bed facility and has grown into a 380 bed not-for-profit hospital Union Hospital is a Regional Referral

More information

Discharge Information

Discharge Information Discharge Information Yes, patients were given information about what to do during their recovery Vikki Choate, MSN, RN, CCM, RN-BC, CPHQ Nashville, TN May 14-15, 2013 Learning Objectives At the end of

More information

Improving Patient Safety Across Michigan and Illinois

Improving Patient Safety Across Michigan and Illinois Improving Patient Safety Across Michigan and Illinois Readmissions Collaborative Kickoff January 20, 2016 1 Agenda Readmissions Collaborative Structure and Overview Business case for readmissions Using

More information

SENTARA HEALTHCARE. Norfolk, VA

SENTARA HEALTHCARE. Norfolk, VA SENTARA HEALTHCARE Norfolk, VA 1 Sentara Healthcare Overview 11 Acute Care Hospitals in Virginia with a total of 2572 licensed beds 1E Extended dstay hospital 9 Ambulatory Care Campuses; 5 with freestanding

More information

TRANSITIONS of CARE. Francis A. Komara, D.O. Michigan State University College of Osteopathic Medicine

TRANSITIONS of CARE. Francis A. Komara, D.O. Michigan State University College of Osteopathic Medicine TRANSITIONS of CARE Francis A. Komara, D.O. Michigan State University College of Osteopathic Medicine 5-15-15 Objectives At the conclusion of the presentation, the participant will be able to: 1. Improve

More information

REDUCING READMISSIONS FOR SNF PATIENTS

REDUCING READMISSIONS FOR SNF PATIENTS REDUCING READMISSIONS FOR SNF PATIENTS Amy E. Boutwell, MD, MPP President, Collaborative Healthcare Strategies New York State Partnership for Patients HIIN September 28, 2017 Objective Identify 3 practical

More information

University Cincinnati Medical Center

University Cincinnati Medical Center University Cincinnati Medical Center Best Practice: The Journey to an Advanced Heart Failure Program Dr. Stephanie H. Dunlap, DO Medical Director of the Advanced Heart Failure program and the Advanced

More information

Bundled Payments to Align Providers and Increase Value to Patients

Bundled Payments to Align Providers and Increase Value to Patients Bundled Payments to Align Providers and Increase Value to Patients Stephanie Calcasola, MSN, RN-BC Director of Quality and Medical Management Baystate Health Baystate Medical Center Baystate Health Is

More information

Reducing Readmissions: Care Transitions Toolkit

Reducing Readmissions: Care Transitions Toolkit Reducing Readmissions: Care Transitions Toolkit 2 nd Edition: February 26, 2014 Right Care at the Right Time in the Right Setting 1 P a g e Washington State Hospital Association - Partnership for Patients

More information

M7: Reducing Avoidable Rehospitalizations. Overview of the Problem and Promising Approaches

M7: Reducing Avoidable Rehospitalizations. Overview of the Problem and Promising Approaches M7: Reducing Avoidable Rehospitalizations Overview of the Problem and Promising Approaches Eric A. Coleman, MD, MPH Director, Care Transitions Program This presenter has nothing to disclose. Session Objectives

More information

5/26/2015. January 26, 2015 INCENTIVES AND PENALTIES. Medicare Readmission Penalties. CMS Bundled Payment Providers & ACOs in NE

5/26/2015. January 26, 2015 INCENTIVES AND PENALTIES. Medicare Readmission Penalties. CMS Bundled Payment Providers & ACOs in NE Agenda ESTABLISHING SHARED EXPECTATIONS New tool of ACOs, Bundled Payments & Readmission Reduction Update on current market pressures driving a focus on care across settings & over time at lowest cost

More information

Presenter Disclosure

Presenter Disclosure Improving Transitions from the Hospital to Community Settings IHI National Forum Learning Lab Sunday, December 9, 2012 Session L20 Presenter Disclosure Leora Horwitz, MD Assistant Professor of medicine

More information

L5: Getting to Always! Using Teach-back to Maximize Patient Learning

L5: Getting to Always! Using Teach-back to Maximize Patient Learning Disclaimers: None L5: Getting to Always! Using Teach-back to Maximize Patient Learning March 21, 2016 Peg Bradke Gail Nielsen Objectives Identify opportunities across the continuum to engage patients and

More information

Readmissions Moving beyond blame to fill the patient needs. Jackie Conrad RN, MBA, RCC Cynosure Health

Readmissions Moving beyond blame to fill the patient needs. Jackie Conrad RN, MBA, RCC Cynosure Health Readmissions Moving beyond blame to fill the patient needs Jackie Conrad RN, MBA, RCC Cynosure Health jconrad@cynosurehealth.org 1 51 year old male with 3 acute care admissions and 2 ED visits in the past

More information

Pharmacy s Role in Decreasing Hospital Readmissions

Pharmacy s Role in Decreasing Hospital Readmissions Pharmacy s Role in Decreasing Hospital Readmissions ACPE UAN 107-000-11-004-L04-P & 107-000-11-004-L04-T Activity Type: Knowledge-Based 0.15 CEU/1.5 Hr Program Objectives for Pharmacists: Upon completion

More information

Healthcare Leadership Council: John Perticone Golden Living 3/9/2016

Healthcare Leadership Council: John Perticone Golden Living 3/9/2016 Healthcare Leadership Council: Care Transitions in Post Acute Care John Perticone Golden Living 3/9/2016 Golden Living Profile Golden Living Centers and Communities 296 skilled nursing facilities 15 assisted

More information

The new role of hospitalists. Keeping patients out of the hospital. Cynthia Litt, MPH Eugene Kim, MD

The new role of hospitalists. Keeping patients out of the hospital. Cynthia Litt, MPH Eugene Kim, MD The new role of hospitalists. Keeping patients out of the hospital Cynthia Litt, MPH Eugene Kim, MD Cedars-Sinai Health System Cedars-Sinai Medical Center Medical Delivery Network Education and Research

More information

Implementation Guide: Critical Interventions in the First/Second Visit. VNAA Best Practice for Home Health

Implementation Guide: Critical Interventions in the First/Second Visit. VNAA Best Practice for Home Health Implementation Guide: Critical Interventions in the First/Second Visit VNAA Best Practice for Home Health Learning Objectives The participant will be able to: Identify three interventions that should take

More information

Redesigning the Role of the RN in Case Management: Impact on HCAHPS and Readmission Rates Session C093. Mercy Health System 09/10/15

Redesigning the Role of the RN in Case Management: Impact on HCAHPS and Readmission Rates Session C093. Mercy Health System 09/10/15 Redesigning the Role of the RN in Case Management: Impact on HCAHPS and Readmission Rates Session C093 2015 ANCC National Magnet Conference Friday October 9th 2015 8:00 a.m. Debra Potempa MSN, RN, NEA

More information

Managing Risk Through Population Health Initiatives

Managing Risk Through Population Health Initiatives Managing Risk Through Health Initiatives Vicki DeBaca, DNS, RN Vice President, Health & Provider Services Sharp Rees-Stealy Medical Centers 1 Sharp Rees-Stealy Medical Centers San Diego s Multi-Specialty

More information

Baptist Health System Jacksonville, FL

Baptist Health System Jacksonville, FL Baptist Health System Jacksonville, FL Baptist Health System Community Leader in Healthcare Five (5) Hospital System Serving greater Jacksonville area and SE Georgia Children s Hospital Primary Care Facilities

More information

Reducing Readmissions: Care Transitions Toolkit

Reducing Readmissions: Care Transitions Toolkit Reducing Readmissions: Care Transitions Toolkit Third Edition: January 1, 2017 Right Care at the Right Time in the Right Setting 1 P a g e Washington State Hospital Association - Partnership for Patients

More information

CHF Education March Courtney Reaves, BSN, RN-BC Amy Taylor, BSN, RN Corey Paris, BSN, RN, CCRN

CHF Education March Courtney Reaves, BSN, RN-BC Amy Taylor, BSN, RN Corey Paris, BSN, RN, CCRN CHF Education March 2015 Courtney Reaves, BSN, RN-BC Amy Taylor, BSN, RN Corey Paris, BSN, RN, CCRN Objectives To improve patient outcomes Decrease CHF readmissions Improve patient and family compliance

More information

Faculty Presenters. The Care Transitions Program. STAAR Initiative

Faculty Presenters. The Care Transitions Program. STAAR Initiative Session M13 These presenters have nothing to disclose 26th Annual National Forum on Quality Improvement in Health Care Minicourse: Reducing Avoidable Readmissions by Creating a More Patient-Centered Transition

More information

How to Initiate and Sustain Operational Excellence in Healthcare Delivery: Evidence from Multiple Field Experiments

How to Initiate and Sustain Operational Excellence in Healthcare Delivery: Evidence from Multiple Field Experiments How to Initiate and Sustain Operational Excellence in Healthcare Delivery: Evidence from Multiple Field Experiments Aravind Chandrasekaran PhD Peter Ward PhD Fisher College of Business Ohio State University

More information

Patient and Family Caregiver Interview Tool

Patient and Family Caregiver Interview Tool Patient and Family Caregiver Interview Tool Instructions: We recommend you select at least 5-10 patients who have been readmitted to your organization within the past 30 days to include in the group of

More information

Glendale Healthier Community Care Coordination Collaborative. Health Services Advisory Group (HSAG) March 06, 2018

Glendale Healthier Community Care Coordination Collaborative. Health Services Advisory Group (HSAG) March 06, 2018 Glendale Healthier Community Care Coordination Collaborative Health Services Advisory Group (HSAG) March 06, 2018 Today s Agenda and Packet Materials Welcome and Introductions Community Readmissions and

More information

DELTA CARE CHANGING LIVES. A CARE TRANSITION PROGRAM of EPHRAIM MCDOWELL HEALTH DR. JOAN HALTOM, PHARM.D, FKSHP GAIL SHEARER, BSN, MBA,CCM

DELTA CARE CHANGING LIVES. A CARE TRANSITION PROGRAM of EPHRAIM MCDOWELL HEALTH DR. JOAN HALTOM, PHARM.D, FKSHP GAIL SHEARER, BSN, MBA,CCM DELTA CARE CHANGING LIVES A CARE TRANSITION PROGRAM of EPHRAIM MCDOWELL HEALTH DR. JOAN HALTOM, PHARM.D, FKSHP GAIL SHEARER, BSN, MBA,CCM DELTA CARE Delta Care is an Innovative approach to transitioning

More information

A Care Transitions Project

A Care Transitions Project Hospital to Home: A Care Transitions Project Ann Roemen, MBA, CMPE Readmissions 1 in 5 elderly patients Resultsin23million 2.3 re-hospitalizations Annual cost to Medicare - $17 billion + Jencks SF,Williams

More information

Stroke Patients: Transition From Hospital to Home

Stroke Patients: Transition From Hospital to Home Stroke Patients: Transition From Hospital to Home Lauren Pond RN CCM Administrative Director, Case Management Jennifer Thiesen RNP CCRN Director, Care Transitions Presenter Disclosure Information Lauren

More information

Session 92AB Improving Patient Experience and Outcomes Using Real-Time Care Rounding Technology

Session 92AB Improving Patient Experience and Outcomes Using Real-Time Care Rounding Technology Prepared for the Foundation of the American College of Healthcare Executives Session 92AB Improving Patient Experience and Outcomes Using Real-Time Care Rounding Technology Presented by: Sue Murphy Alison

More information

The Stepping Stones Project Care Transitions and the Coaching Model

The Stepping Stones Project Care Transitions and the Coaching Model The Stepping Stones Project Care Transitions and the Coaching Model Selena Bolotin, MSW Care Transitions Project Manager Quality & Safety Initiatives Qualis Health Seattle, Washington About Qualis Health...

More information

10/27/10. Michelle Mourad MD Arpana Vidyarthi Ellen Kynoch. pulmonary edema. sodium intake & daily weights

10/27/10. Michelle Mourad MD Arpana Vidyarthi Ellen Kynoch. pulmonary edema. sodium intake & daily weights Michelle Mourad MD Arpana Vidyarthi Ellen Kynoch pulmonary edema sodium intake & daily weights 1 What makes her at risk for readmission? Why didn t she listen to her doctors about her salt intake? Did

More information

CMS Oncology Care Model s Standards for Patient Navigation

CMS Oncology Care Model s Standards for Patient Navigation CMS Oncology Care Model s Standards for Patient Navigation Nikolas Buescher Executive Director of Cancer Services Penn Medicine, Lancaster November 13, 2017 Ann B Barshinger Health Cancer Institute scale

More information

ASPIRE to Reduce Readmissions

ASPIRE to Reduce Readmissions ASPIRE to Reduce Readmissions Amy E. Boutwell, MD, MPP President, Collaborative Healthcare Strategies Objectives Explain the value of a data-informed, whole-person approach to reducing readmissions Identify

More information

Improving Care Transitions

Improving Care Transitions Care Transitions Collaborative Improving Care Transitions Laura Cole, RN South Carolina Partnership for Health SPECIFIC QUESTIONS WE WILL EXPLORE TODAY: Why the focus on care transitions? What strategies

More information

FHA HIIN Readmissions Peer Sharing Webinar: Improving Care Transitions through a Discharge Lounge. July 24, 2018

FHA HIIN Readmissions Peer Sharing Webinar: Improving Care Transitions through a Discharge Lounge. July 24, 2018 FHA HIIN Readmissions Peer Sharing Webinar: Improving Care Transitions through a Discharge Lounge July 24, 2018 Welcome & Overview How are we doing on Reducing Readmissions? Peer Sharing Presentation:

More information

Institutional Handbook of Operating Procedures Policy

Institutional Handbook of Operating Procedures Policy Section: Clinical Policies Institutional Handbook of Operating Procedures Policy 09.01.13 Responsible Vice President: EVP and CEO Health System Subject: Admission, Discharge, and Transfer Responsible Entity:

More information

Transitions of Care: From Hospital to Home

Transitions of Care: From Hospital to Home Transitions of Care: From Hospital to Home Danielle Hansen, DO, MS (Med Ed) Associate Director, LECOM VP Acute Care Services & Quality/Performance Improvement, Millcreek Community Hospital Objectives Discuss

More information

2017 Edition. MIPS Guide. The rule is in and Medicare physician payments are changing. What does that mean for you?

2017 Edition. MIPS Guide. The rule is in and Medicare physician payments are changing. What does that mean for you? 2017 Edition MIPS Guide The rule is in and Medicare physician payments are changing. What does that mean for you? MERIT-BASED INCENTIVE payment system The Merit-based Incentive Payment System (MIPS) combines

More information

Transition of Care Model for Inpatient & Observation Units

Transition of Care Model for Inpatient & Observation Units V.2 Transition of Care Model for Inpatient & Observation Units TRANSITION OF CARE PROGRAM FOR INPATIENTS & OBSERVATION UNITS (TOC) SCC PROJECT MANAGEMENT OFFICE TOC MODEL FOR INPATIENT & OBSERVATION UNITS

More information

Creating A Niche: Medical-Surgical Nurses Role in Succesful Program Development (Oral)

Creating A Niche: Medical-Surgical Nurses Role in Succesful Program Development (Oral) Lehigh Valley Health Network LVHN Scholarly Works Patient Care Services / Nursing Creating A Niche: Medical-Surgical Nurses Role in Succesful Program Development (Oral) Eileen Sacco MSN, RN, CNRN, ONC

More information

Care Transitions Partnerships that Work for Patients

Care Transitions Partnerships that Work for Patients Care Transitions Partnerships that Work for Patients Alyce Brophy, President/CEO, Community Visiting Nurse Association Alyssa Kizun, Director, Care Management, Somerset Medical Center Stacey Wilbur, Administrator,

More information

PARAMEDIC-NURSE READMISSION PROJECT VALLEY AMBULANCE- REGIONAL WEST MEDICAL CENTER

PARAMEDIC-NURSE READMISSION PROJECT VALLEY AMBULANCE- REGIONAL WEST MEDICAL CENTER PARAMEDIC-NURSE READMISSION PROJECT VALLEY AMBULANCE- REGIONAL WEST MEDICAL CENTER PROJECT PURPOSE To reduce hospital readmissions for CHF, pneumonia patients To improve patient satisfaction with the discharge

More information

Improving Transitions of Care

Improving Transitions of Care Improving Transitions of Care Mark V. Williams, MD, FACP, FHM Professor & Chief, Division of Hospital Medicine Northwestern University Feinberg School of Medicine Principal Investigator, Project BOOST

More information